Action Points

Limiting lung cancer screening to high-risk smokers and former smokers who quit within the past decade could improve the cost-effectiveness of screening programs.

Note that contrary to expectations, the analysis found annual screening to be more cost effective than biennial screening.

Limiting lung cancer screening to high-risk smokers and former smokers who quit within the past decade could improve the cost-effectiveness of screening programs, according to a microsimulation modeling analysis of more than 500 different screening policies.

The most cost-effective scenario identified in the analysis was annual screening of smokers between the ages of 55 and 75 with 40 pack-years or more of smoking, or former smokers with ≥40 pack-years who quit smoking less than 10 years prior to screening assessment, reported Lawrence F. Paszat, MD, of the Institute for Clinical Evaluation Sciences Ottawa Hospital Research Institute in Toronto, and colleagues.

Contrary to expectations, the analysis found annual screening to be more cost effective than biennial screening, they wrote in PLOS Medicine.

This screening strategy was estimated to reduce lung cancer mortality by 9.05% compared with no screening, with an incremental cost-effectiveness ratio of $33,825 U.S. dollars per year of life gained.

This finding suggests that limiting screening to people with substantial smoking histories may allow lung cancer screening to be implemented in a cost-effective manner, the researchers noted.

"The level of lung cancer risk at which an individual is eligible for lung cancer screening should be considered before implementing lung cancer screening policies," the researchers wrote. "Future research should investigate the cost-effectiveness of lung cancer screening selection based on accurate lung cancer risk prediction models using suitable risk thresholds."

The U.S. Preventive Services Task Force (USPSTF) recommends annual lung cancer screening with low-dose CT for smokers between the ages of 55 to 80 who have at least a 30-pack-year smoking history and former smokers quitting within the past 15 years of the same age and smoking history, provided the person has a normal life expectancy.

The American Lung Cancer recommends that clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with patients, ages 55 to 74, who have at least a 30-pack-year smoking history, currently smoke or have quit within the past 15 years, and who are in relatively good health.

"Despite lung cancer screening being recommended by a number of organizations, the cost-effectiveness of lung cancer screening is uncertain; concerns have been raised on the potential costs of implementing lung cancer screening," the researchers wrote.

They noted that past studies evaluating the cost-effectiveness of screening considered just a few screening policies and provided limited information on how different characteristics of the policies impacted the cost-effectiveness of screening.

The microsimulation model was used to analyze 576 different lung cancer screening policies starting in 2015 for people born from 1940 to 1969 in Ontario, Canada. The scenarios varied by age at the start and end of screening, smoking eligibility criteria, and screening interval.

"Assuming a cost effectiveness threshold of $50.000 Canadian dollars ($41,114 U.S. dollars in May of 2015) per life-year gained as acceptable for the Canadian health care system, Scenario #2 was considered optimal: current and former smokers (who quit ≤10 years ago) who smoked ≥40 pack-years would be screened annually between ages 55-75, yielding an incremental cost effectiveness ratio (ICER) of $41,136 Canadian dollars ($33,825 U.S., May 1, 2015) per life-year gained," the researchers wrote.

While conceding that the strategy would not identify as many cancers as that used in NLST, they concluded that it would be more cost effective, while reducing false-positive screens and lung cancer overdiagnosis.

In an accompanying editorial, Steven D. Shapiro, MD, of the University of Pittsburgh Medical Center, wrote that refining lung cancer screening criteria in the era of value-based medicine remains a challenge.

"The hard fact remains that when cost-effectiveness enters the decision of whether to screen, some cancers will be missed that otherwise could have been caught early and cured," he wrote."Cost-effectiveness thresholds like the one used in this manuscript -- modeled to be effective if disease-related costs per life-year gained were less than $50,000 Canadian dollars -- is reasonable, albeit somewhat arbitrary, and may be best determined by a nation's societal values and capability."

He added that while the fine-tuning of screening strategies and advances in imaging should lead to improved early diagnosis in the future, "it is important not to lose sight of the fact that if smoking were eliminated, then lung cancer would be an orphan disease."

The study was funded by the Ontario Ministry of Health and Long-Term Care, Cancer Care Ontario and the Ontario Institute for Cancer Research.

Some co-authors disclosed support from the Dutch National Institute of Public Health and the Environment and The Netherlands Organization for Health Research and Development.

Paszat and co-authors disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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